Upper GI Bleed

Question 1

What are the main causes of UGI bleeds

Answer 1

Vascular
-esophageal varices

Iatrogenic/idiopathic
-NSAIDs, aspirin, anticoagulants, steroids => peptic ulcers

Trauma
-Mallory Weiss tear

Infective/inflammatory
-esophagitis, gastritis

Neoplastic
-malignancy

Question 2

Types of peptic ulcer

• causes
• managemen

Answer 2

Gastric, duodenal (erosion of gastroduodenal artery causes heavy bleeding)

• Hpylori - urea breath test/stool antigen => PPI + amoxicillin + clarythromycin + metronidazole
• NSAIDs, smoking, alcohol, stress => PPI

Repeat OGD in 6-8wks due to risk of malignancy

Question 3

Mallory Weiss tear

-presentation

Answer 3

Severe vomiting => Gastroesophageal junction bleed => hematemesis

• no prior systemic upset or symptoms
• self limiting

Question 4

Gastric, esophageal malignancy

• presentation
• risk factors

Answer 4

Adenocarcinomas most common

Esophagus - GERD, Barrett’s esophagus, smoking, obesity
-Dysphagia, anorexia, weight loss
Vomiting, melena, hoarse voice

Stomach - HPylori, smoking, salt preserved food
-Abdo pain, indigestion, dysphagia
Weight loss, anorexia
N+V

Question 5

What is esophagitis associated with?

What is gastritis associated with?

Answer 5

Esophagitis - GERD
-small volume of blood, self limiting

Gastritis - NSAIDs
-unlikely cause of bleeding

Question 6

Management of all acute UGI bleeds

Answer 6

Resus - A-E

• 2 wide bore IV cannula
• Platelets U50 AND actively bleeding => platelet transfusion
• Fibrinogen U1.5g or high PT/aPTT => FFP (can add CP if needed)
• Warfarin users => prothrombin complex + VitK

Endoscopy
-immediately after severe bleed or within 24hrs

Question 7

Management of non variceal hemorrhage

-acute - definitive

Answer 7

Definitive

-endoscopic clips, thermal coagulation/argon laser + PPIs

Question 8

Management of variceal hemorrhage

• acute - initial and definitive
• prophylaxis

Answer 8

Initial

• terlipressin
• prophylactic IV ABx for liver cirrhosis - quinolones

Definitive
-endoscopic variceal band ligation or TIPSS

Prophylaxis

• propanolol
• endoscopic variceal band ligation every 2wks

Question 9

Presentation of UGI bleeds

Answer 9

Hematemesis - bright red or coffee grounds
Melena - black tarry stools
High urea due to high protein content of blood
Features associated with particular diagnosis

Question 10

Risk assessments of all UGI bleeds

Answer 10

Blatchford Score - assess for OP management
-Not 0 - IP management

Rockall Score - pre and post endoscopy score for adverse outcomes

• U3 = good prognosis
• 8+ = high mortality